The Infrastructure of the Opioid Epidemic

On Boston’s “Methadone Mile,” the city’s opioid users cluster around a few-block-stretch, where they find some support, and a sweeping range of treatment services. They are also out of sight of the rest of the city.

BOSTON—Michael Young, 40, stands on the corner of Massachusetts Avenue and Melnea Cass Boulevard. On his left, cars whir past; on his right, about two dozen people line up along the chain link fence overlooking Boston’s Interstate 93, some drifting in and out of consciousness, others plotting their next high.

Within a two-block radius of this street corner is the Boston Medical Center, homeless shelters, numerous methadone and suboxone clinics, and an open air drug market. “They have everything right here,” says Gwendel Wilson, 54, with his arms stretched. Wilson, along with Young, sleeps on this dusty strip of grass some nights. “It’s all condensed.”

While many cities cluster health services, and have hotspots for certain kinds of drug use, Boston is unique in that here the two clusters overlap, creating a longstanding culture of both illicit opioid use and rehabilitation. “It’s bringing together people who are both seeking solutions and those that may not be in treatment but are struggling with drug addiction,” says Robert Sampson, the co-director of the Boston Area Research Initiative.

The Diagnosis

Boston was one of the early U.S. cities to confront an opioid epidemic that has expanded from prescription painkiller abuse, to heroin, to ever-more potent strains, and complex cocktails of drugs.

While opioid use in this part of town predates the epidemic, experts say the spike in overdose deaths among the homeless population here, on the border of the South End and Roxbury, began to spike between 2003 and 2008. The same spike in deaths was not seen in the rest of the city or nation until at least 2012.

Over time, the city in coordination with nonprofits has capitalized on the natural clustering of people who abuse opioids to offer an ever-expanding array of services. These services have, in turn, facilitated even more people to cluster in the neighborhood, with people across the state sometimes relocating to this few-block stretch.

“It’s almost like we’ve had to build infrastructure to manage complex overdoses.”

Most recently, the city opened a new no-questions-asked day shelter known as an “engagement space” to steer people off the streets, hopefully into treatment.

Before that, the nonprofit Health Care for the Homeless, in coordination with the city, opened a medical facility specifically focused on “complex overdoses” typically suffered by those who have taken heroin and fentanyl along with a cocktail of other pills—a combination many in the area turn to to prolong their high.

All of this has created a distinct stretch of land where much of the city’s opioid problem is relegated, out of sight and out of mind for much of the rest of the city.

The virtues and perils of clustering

This is a part of town known by many names; its precise borders are ill defined. Colloquially, it’s called “Methadone Mile,” a name healthcare workers bristle at, claiming it stigmatizes both the individuals who seek treatment and the treatment itself. But standard neighborhood designations—the edge of South End, Roxbury, or Newmarket—don’t quite fit either.

Informal markers are more definitive. People tend to walk toward the area in a determined march and away in a foggy stupor. Men with backpacks may whisper “brown” and “that hard” in your ear as you pass, and you’ll see a large number of people wearing lanyards with medical IDs hanging around their necks.

In recent years there has been a swell of people drawn to the area, in part due to the deluge of people caught up in the opioid epidemic ravaging New England, and the city’s abrupt decision to close Boston’s Long Island due safety concerns with the bridge there. More than 700 people living in shelters and addiction and treatment centers there were forced to evacuate.

Michael Young has been living on the streets of “Methadone Mile” or in nearby shelters for six years. (Susan Zalkind)

Officials, advocates, and even inhabitants of the neighborhood have mixed views on the virtues of the opioid-centric tone that has emerged.

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“It’s obviously caused some issues in the area,” says Lieutenant Detective Brian J. Larkin, the commander of the Boston Police Drug Control Unit, of the closing of the shelter and the escalating opioid epidemic.

Larkin says that the cluster of health and homeless services creates an easy target for drug dealers, and that “it would be good to displace it and maybe put some resources around the city.

“But then it gets to the question, do you want it in your backyard?”

This is the not-in-my-backyard, or NIMBY, question that Boston and many other cities confront when they try to site addiction treatments across a city. When these facilities work well, they attract people who use drugs and want help to the neighborhood. This leads many residents to oppose the facilities altogether—particularly those that aim to protect the health of even those individuals who keep using—on the basis that they may have adverse consequences on the neighborhood.

Jennifer Tracey, head of the city’s Office of recovery Service, says the pushback when trying to introduce services to other parts of the city can be intense. For every new service, the city has faced protest from local business owners worried the facility may increase “congestion” to the area.

Keeping services in one limited area alleviates some of this resistance. And it also allows the city to offer people “multiple pathways to engagement” all in one place.

“You just know if something happens, you know that you have certain people that regardless are going to have your back.”

But service providers have faced resistance to development along “Methadone Mile,” too. Business owners say they find loitering frustrating, citing an uptick in petty crime, public urination, and overdoses. A Cumberland Farms chain on the corner of Massachusetts Avenue and Melnea Cass Boulevard was for a time considered to be the epicenter of “Methadone Mile” and crowds gathered outside. Opened in 2013, the chain store closed in 2016 after citing a lack of support for overwhelming number of those in the area struggling with addiction.

To address concerns, especially around a new service that hosts and monitors those who are already intoxicated, Dr. Jessie M. Gaeta, the Chief Medical Officer of the Boston Health Care for the Homeless Program, says she has attended 40 community meetings in the last 18 months.

The cluster of services also presents what Tracey sees as another downside: “People come here from different parts of the state, mainly because of the services, at the same time not knowing other people.”

“Come as you are”

On a Friday afternoon, a half dozen men are seated in lazy boys, nearly or all the way unconscious. Five of them have their vital signs monitored. One, who is still able to respond to a nurse, has a box of juice on his lap. If any of them show signs of overdose, the nurse there will revive them with naloxone, which reverses the effects of overdose.

This is Supportive Place for Observation and Treatment (SPOT), the program which monitors those who are high on opioids.

SPOT falls short of a supervised injection clinic; there are no legal supervised injection clinics in the United States, though reportedly at least one underground clinic exists. When people overdose on heroin or fentanyl, they generally react to the drug at the point of injection, or shortly thereafter. Because those who use SPOT’s services are not permitted to use drugs in the facilities, caretakers often miss those overdoses. But because “cocktails” of drugs often takes longer to take effect, Gaeta says SPOT is useful here. Most people who use the services have just injected heroin, or are carried or wheeled in by friends.

Gaeta says the center has serviced 3,800 encounters among a population of 500 individuals. One third of visits here have prevented a trip to emergency rooms, and 10% of those who visit have gone on to seek opioid treatment. She says the program is especially useful to women, many of her clients have been assaulted while intoxicated elsewhere.

The facility is focused specifically on monitoring the “complex overdoses” typically suffered by those who have taken heroin and fentanyl along with the local “cocktail” of other pills to prolong the high, run by the non-profit Health Care for the Homeless. This program is also a year old.

“It’s almost like we’ve had to build infrastructure to manage complex overdoses,” says Gaeta.

The newest facility in the neighborhood is a city sanctioned-an “engagement center” with a capacity of 100, built out of a massive tarp tent once used as the cooking facility on Boston’s Long Island Shelter, where nurses from the Boston Health Care for the Homeless program also provide free treatment.

On a Tuesday afternoon at the engagement center a woman in a pink and white striped tank top, and a large half full Dunkin Donuts iced coffee, steps through the 90-degree heat, amplified by the omnipresent concrete, past the sign which reads, “COME AS YOU ARE” and into the cool of the tent.

She catches herself as she stumbles over her flipflops. “So hot,” she says under her breath before taking a seat, joining about 30 others inside, watching Black Hawk Down on TV, reading from the small library of books, watching videos on Youtube, and charging their phones. Behind her a man is writing on a piece of cardboard with a thick red pen, “OFFSHORE FISHERMAN OUT OF WORK.”

Of the four staff members overseeing the center that day, no one takes her name as she walks through the door. She does not go through security, and no one checks her pockets. And that’s the point, says Devin Larkin, director of the Recovery Services Bureau at the Boston Public Health Commission and no relation to Brian Larkin. She says the day shelter was built to attract people, “who don’t have a lot of trust in systems.”

Robert Johnson, after receiving treatment at Boston Medical Center. He says he's been sober for 4 years. “I said one day I don’t want no more.” (Susan Zalkind)

The day shelter was built with the needs of the region specifically mind. Larkin said the group consulted with five different business associations with interest in the area, as well as clients.

“Most people referred to detox are new to the area,” explains Larkin.

So far, says Larkin, the center is working: Most people who have visited come back.

This group includes Young. “It’s a cool place,” he says.

“The chaos and the friendship”

The corner where Young stands, the busy, nondescript intersection once slated for an interstate that never came, along the site where some once hoped the 2024 Olympics would take place, is arguably the epicenter of this informal neighborhood.

Fallon Aidoo, a transportation and land use planning consultant and university lecturer, says it is unusual to see a mix of hospital and social services in the same city corridor bringing together “patients of every demographic who might be grappling with opioid abuse.”

Aidoo says the “hodgepodge of infrastructure” with BMC on one end and the South Bay Center shopping plaza on the other, with industrial facilities in between is the product of urban renewal, which also resulted in the clearing of an African American community which once stood in its place.

Sampson points to the lack of residential homes as one reason why the open-air-drug market has taken root here. “You might think of it as a no man’s land in the sense of ownership,” he says.

But others say the community on the streets is precisely what keeps them here.

Young has been living outside or in nearby shelters for six years. He uses the medical services offered here, but says he is drawn to this part of town for the “chaos and the friendship.”

“You just know if something happens, you know that you have certain people that regardless are going to have your back,” he says. “We move from one place to another. If they kick us out of here, we just go to a new spot, and then they kick us out of that spot and then we just go to a new spot.”

This article is part of our project, “The Diagnosis,” which is supported by a grant from the Robert Wood Johnson Foundation.

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